AUTHORIZATION FOR RELEASE OF INFORMATION

Patient’s Name:

Date of Birth:

I hereby AUTHORIZE and give consent to:

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

To RELEASE healthcare information on the above named patient TO:

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

This request and authorization applies to the following: (Select one)

No Limitations The following dates only Other

If you selected The following dates only, please specify Start Date and End Date:

Start Date:

End Date:

If you selected Other, please specify:

And for the following reason or purpose:

Continued medical care Other

If you selected Other, please specify:

This authorization to release confidential information may be revoked by me in writing at any time, except to the extent that the action has taken in reliance on it. It shall be effective only long enough to fulfill the specific purpose for which it is given or for sixty days, whichever comes first. No further confidential information will be released without the execution of an additional written statement of consent. I understand that I am not required to give this consent, and that I can refuse without any prejudice to my future treatment at Affiliated Dermatologists of Virginia.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Parent/Authorized Representative

Date of Consent:

Your information will be encrypted.